The increased prevalence of cognitive deterioration has increased the challenges of caring for older adults. This study's project site offers a psychiatric program for older adults with customized care for complex geriatric mental health patients. Clinical assessment and care management are often overlooked in geriatric mental health patients diagnosed with behavioral and psychological symptoms of dementia (BPSD). The purpose of this project was to deliver an education program developed from the Staff Training in Assisted Living Residences-Veterans Administration, P.I.E.C.E.S model and the Castle framework to 42 nursing and allied health staff of the project site. The project question explored whether an education program on care of patients with BPSD increased staff members' perceived knowledge and competence in providing care to these patients. This education program focused on comprehensive assessment, individualized care planning, and individualized nonpharmacological interventions to manage older adults with dementia. Descriptive statistics were used to analyze performance outcomes data before and after staff education. In addition, care plans of patients were reviewed. Results included a 100% increase in recognition of core concepts of the education program; a 48% to 86% increase in staff willingness to use interdisciplinary care plans; and a 6.6% to 95% increase in documentation of key interventions in care plans for 6 behaviors of dementia. The results of this project might bring about social change by improving the skills and competence of nursing staff in managing the patients with dementia, thus positively impacting the quality of life of patients with BPSD by benefiting from nonpharmacological interventions.

The purpose of this article is to synthesize the evidence on advance care planning (ACP), determine what is applicable to the home health (HH) setting, and find where gaps in knowledge may exist. An integrative review methodology was chosen. Although there is ample literature on the topic of ACP, most research has been conducted in the acute care, outpatient, and general community settings. There is limited literature regarding ACP with patients living with chronic cardiovascular and pulmonary illnesses, who comprise the majority of the HH population. Some literature has been published regarding the interprofessional team's role in ACP in the HH setting. A gap in knowledge exists regarding ACP in HH, and recommendations for future research are provided.

BACKGROUND: Studies have consistently demonstrated low rates of adoption of Advance Care Planning in the community. METHODS: We studied Medicare enrollees age 65 and over and non-Medicare patients using a cross-sectional survey undertaken in February and March 2019 using questionnaires completed by out-patients attending a teaching hospital clinic in East Tennessee USA. We evaluated patient knowledge, attitudes, satisfaction and aspirations towards Advance Care Planning. RESULTS: 141 properly completed questionnaires were used. All Medicare enrollees were aware of Advanced Care Planning compared to 43% in the non-Medicare group. 70% of the Medicare enrollees and 94% of non-Medicare group were not ready to complete a written Advanced Care Plan. Of the respondents, 46% had appointed spouses, 24% adult children, 11% siblings, 10% parents, 3.6% friends and 1.2% aunts as their surrogate medical decision makers. 41% agreed that they were satisfied with their current advance care planning arrangements. This research identified that individual's knowledge, attitudes and aspirations influenced the adoption of Advance Care. CONCLUSIONS: Patients have adopted the Advance Care Plan concept but have modified it to reduce their concerns by using family and loved ones to convey their wishes instead of filling the required legal documents. Clinicians could improve this informal system and increase the observability of the treatment choices including the use of video and web-based tools.

Aim. The aim of this study was to examine the relationship of advance care planning protocols with hospitalization, rehospitalization, and emergency department use rates in U. S. home health agencies (HHA). Background. Since 2003, CMS has required HHAs to report on quality outcomes such as hospitalization, rehospitalization, and emergency department use rates, made publicly available online. Advance care planning (ACP) is a conversation about beliefs, goals, values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on ACP have taken place outside of HHAs among populations with serious illnesses such as HIV/AIDS, cancer, dementia, and end stage renal disease. Meanwhile, the U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses. Effective January 1, 2016, the Center for Medicare and Medicaid Innovation implemented the Home Health Value-Based Purchasing (HHVBP) Model among home health agencies (HHAs) in nine states representing each geographic region in the United States. Agencies in these states began competing on value in the HHVBP model, and reimbursement rates began to be tied to quality performance (innovation.cms.gov). As part of HHVBP, CMS implemented an additional process-level mandate requiring them to report on ACP, though this data is not publicly available. It is currently unknown how ACP protocols in HHAs may affect agencies’ overall rates of acute care services use. Methods. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics, diagnoses, hospitalization, rehospitalization, and ED use were accessed online via CMS websites. Descriptive and regression analyses were conducted using the electronic survey results and the existing data. Results. Associations between the variables were observed and compared to the hypotheses. Statistical significance was found in the relationship between ACP protocols and hospitalization, where one increased the other increased. Several trends were found: Agencies with increased total percentage of cardiac and pulmonary diagnoses tended to have increased hospitalization rates; agencies with increased average age of patients tended to have increased ACPP scores; and agencies with increased proportion of Black patients tended to have higher hospitalization rates.

En raison des multiples choix de traitements qui prolongent la vie, les décisions en matière de soins sont complexes pour les patients en oncologie. La planification préalable des soins (PPS), qui commence dès le diagnostic, permet de réfléchir et de communiquer ses valeurs et ses volontés en ce qui concerne les soins à venir, surtout en situation d’inaptitude. Particulièrement à la suite des changements législatifs au Québec avec la Loi concernant les soins de fin de vie (Éditeur officiel du Québec, 2014), il est important de pouvoir décrire l’expérience des professionnels de la santé avec cette clientèle. Cette étude a pour but d’explorer la perception des infirmières face à la PPS avec les personnes hospitalisées vivant avec un cancer. Comme cadre de référence, le présent mémoire s’appuie sur le Modèle humaniste des soins infirmiers UdeM (Cara et al., 2016). Dans le cadre de cette étude qualitative descriptive interprétative, des entretiens individuels semi-structurés ont eu lieu auprès d’infirmières (n=7) travaillant sur une unité de soins desservant une clientèle hospitalisée en oncologie et en soins palliatifs. Les résultats révèlent une confusion sur la PPS et une association de celle-ci avec les discussions de fin de vie. Pour les infirmières, la PPS est perçue comme un défi, qui est plus facilement surmonté quand l’état de santé se détériore. Des facteurs d’influence par rapport à la personne, l’environnent et le soin sont aussi décrits. La particularité de l’étude est le point de vue des infirmières sur une unité de soins dans le contexte québécois. / Oncology patients face increasingly complex care decisions because of the multiple treatment options that extend life. Advance care planning that begins early allows the patients to reflect and communicate their values and wishes regarding future care, especially when unable to do so. Particularly following the legislative changes in Quebec concerning end-of-life care, it is important to be able to describe nursing experience in ACP with oncology clientele. The purpose of this study is to explore the nurses’ perception of advance care planning (ACP) with hospitalized cancer patients. It is based on the framework of the Humanistic Model of Nursing Care – UdeM (Cara et al., 2016). For this qualitative study of interpretive description, individual semi-structured interviews were conducted with nurses (n = 7) working on a unit taking care of patients in oncology and in palliative care services. The results reveal nurses’ confusion about ACP and a direct association with the end-of-life discussion. For oncology nurses, ACP is a challenge, which is more easily overcome when their patient’s health condition deteriorates. Influencing factors in relation to the person, the environment and the care are also described in the results. The unique feature of this study is the nurses' point of view, in the context of inpatient oncology in Quebec.

<p><strong>Background:</strong> The objective of this mixed methods study is to understand, from the perspectives of seriously ill hospitalized patients, the effect of modifiable physician behaviours on the perceived quality of end-of-life and ACP communication. <strong></strong></p> <p><strong>Methods:</strong> A convergent parallel mixed methods design is used. Participants were recruited from inpatient medical wards at two academic hospitals, and a population with a high risk of mortality at 6-12 months was selected. In the quantitative strand, a questionnaire was administered to measure patients’ self-rated satisfaction with their physician’s ACP communication skills. The primary analysis involved calculation of the strength of correlation between individual QOC items and a global satisfaction score. In the qualitative strand, interpretive description methods were used to explore seriously ill patients’ perceptions of the quality of ACP communication with their physicians. The mixed methods analysis phase involved the creation of a merged analysis table.</p> <p><strong>Results: </strong>From the quantitative strand, three priority behaviours pertained to eye contact, providing full attention, and listening. The three major qualitative themes related to nonverbal behaviours; situating a patient in the context of their background, family and social roles; and assisting patients to make the challenging end-of-life transition. The merged analysis allowed for a fuller, contextualized understanding of why the QOC items with the strongest correlation measures were important from a patient perspective.</p> <p><strong>Conclusions:</strong> This mixed methods study is well-positioned to understand, holistically and from the patient perspective, physician behaviours that influence quality of communication at the end of life.</p> / Master of Science (MSc)

No / The English End of Life Care Strategy promises that all patients with advanced, life limiting illness will have the opportunity to participate in Advance Care Planning (ACP). For patients with Chronic Obstructive Pulmonary Disease (COPD), the barriers to this being achieved in practice are under-explored. Five focus groups were held with a total of 39 health care professionals involved in the care of patients with COPD. Participants reported that discussions relating to ACP are very rarely initiated with patients with COPD and identified the following barriers: inadequate information provision about the likely course of COPD at diagnosis; lack of consensus regarding who should initiate ACP and in which setting; connotations of comparing COPD with cancer; ACP discussions conflicting with goals of chronic disease management; and a lack of understanding of the meaning of 'end of life' within the context of COPD. The findings from this study indicate that, for patients with COPD, significant service improvement is needed before the objective of the End of Life Care Strategy regarding patient participation in end of life decision-making is to be achieved. Whilst the findings support the Strategy's recommendations regarding an urgent for both professional education and increased public education about end of life issues, they also indicate that these alone will not be enough to effect the level of change required. Consideration also needs to be given to the integration of chronic disease management and end of life care and to developing definitions of end of life care that fit with concepts of 'continuous palliation'.

Abstrakt: Okontrollerade symptom och upprepade sjukhusinläggningar kännetecknar den sista tiden i livet hos en del patienter med mycket svår KOL. Trots att det finns en växande insikt att tidig integration av palliativ vård förbättrar patientens symtombehandling och livskvalitet, dör majoriteten av patienter med KOL utan tillgång till palliativ vård. Sjuksköterskor i hemsjukvården har en central roll när det gäller att identifiera och hantera patienternas palliativa vårdbehov. Syfte: Syftet med denna studie är att belysa hur sjuksköterskor i hemsjukvården upplever den palliativa vården av patienter med mycket svår KOL. Metod: Kvalitativ studie där 11 semistrukturerade intervjuer bearbetats med kvalitativ innehållsanalys. Resultat: Insamlat datamaterial resulterade i tre kategorier som påvisar förutsättningar för god palliativ vård i hemmet: 1) Personella och organisatoriska resurser i hemsjuk- och primärvården där stora brister i samarbetet med primärvården samt bristande resurserna för god vård i hemmet noteras. 2) Planering och kommunikation där bristande kommunikation med patienten och mellan olika vårdinsatser samt planering kring patientens vård poängteras. 3) Kunskap där ett behov av att utöka kunskapen om KOL och palliativ vård hos alla yrkeskategorier uppmärksammas. Konklusion: Patienter med mycket svår KOL får ofta en god palliativ vård i livets absoluta slutskede. Resultatet visar dock att patientens vård under de sista månaderna i livet ofta upplevs som oklar och diffus, vilket pekar på att palliativ vård behöver integreras tidigare i vården av patienter med mycket svår KOL. I kommunikations- och planeringsprocessen med patienten har sjuksköterskor en samordnande roll som behöver specificeras och utrustas med de erforderliga personella och organisatoriska resurserna, kunskaperna och befogenheterna. / Abstract: Uncontrolled symptoms and repeated hospitalizations characterize the last period of life in some patients with very severe COPD. Although there is a growing recognition that early integration of palliative care improves the treatment of patient's symptoms and quality of life, the majority of patients with COPD dies without access to palliative care. Nurses in home care have a central role in identifying and managing patients' palliative care needs. Aim: The purpose of this study is to examine how nurses in home care and in nursing homes experience palliative care of patients with severe COPD. Method: Qualitative study in which 11 semi-structured interviews processed using qualitative content analysis. Results: Collected data resulted in three categories that indicate conditions for good palliative care in the home: 1) Human and organizational resources in home- and primary care, where serious deficits within primary care and resources for good home care is noted. 2) Planning and communication, where the lack of communication with the patient and between different health care institutions as well as care planning is emphasized. 3) Knowledge, where a need to improve knowledge of COPD and palliative care for all care professions is recognized. Conclusion: The result shows that the patient's care during the last months of life is often perceived as vague and diffuse, suggesting that palliative care needs to be integrated earlier in the care of patients with very severe COPD. In the communication process and care planning with patients, nurses have a coordinating role that needs to be specified and equipped with the requisite human and organizational resources, skills and competences.

Historicamente, usuários de drogas são submetidos a tratamentos em instituições fechadas que enfocam a abstinência, sem que haja uma participação ativa do usuário nas escolhas e decisões. O Centro de Atenção Psicossocial para Usuários de Álcool e Drogas (CAPS-ad) é um serviço substitutivo ao hospital psiquiátrico que preconiza a participação do usuário em seu tratamento, no sentido de promover sua autonomia e reinserção social. Esta pesquisa tem como objetivo analisar a participação dos usuários de álcool e outras drogas na elaboração e condução de seu projeto terapêutico singular (PTS). Trata-se de uma pesquisa de abordagem qualitativa, do tipo estudo de caso, com usuários do CAPS-ad de um município do interior de Minas Gerais. Foram utilizados como instrumentos de pesquisa a entrevista semi-estruturada com usuários e profissionais do serviço, a análise de prontuários e do formulário de PTS, e a observação participante nos atendimentos de revisão de PTS. Buscou-se analisar se os planos de tratamento traçados consideram a participação efetiva do usuário na busca dos objetivos e metas compartilhados, com vistas à inserção social e ao resgate da cidadania. Pretende-se também entender o grau de responsabilização do usuário pelo próprio tratamento, avaliando os objetivos e as motivações dos usuários e profissionais do CAPS-ad. Divergências entre objetivos de usuários e de profissionais foram reveladas, demonstrando haver presença de caráter tutelar e pouca responsabilização de alguns usuários no seu tratamento. Observou-se também uma limitação no uso do instrumento PTS, com pouca participação dos usuários em sua elaboração, e sem apresentação de metas e propostas de ações singulares. Foi proposto um novo formulário de PTS que incentive o protagonismo do usuário no tratamento e que contemple diversos aspectos de sua vida. Nesta abordagem, torna-se necessário uma capacitação dos usuários sobre as premissas do tratamento, de forma a promover sua autonomia e participação efetiva na elaboração do PTS. / Throughout history, drug users have been treated in closed institutions that focus on abstinence, lacking an active participation from the user in choices and decisions. The Psychosocial Care Center for Alcohol and Drug Users (CAPS-ad) is a service that replaces the psychiatric hospital which advocates for the user’s participation in their treatment, in order to promote their autonomy and social reintegration. This research aims to analyze the participation of alcohol and other drugs users in the elaboration and conduction of their Singular Therapeutic Project (PTS). This is a qualitative, case study type research, with CAPS-ad users of a municipality in the countryside of Minas Gerais. The semi-structured interview with users and professionals from the field, the analysis of medical records and PTS form, and the participant observation in the PTS review visits were used as research instruments. This research aims to analyze whether the drawn treatment plans consider the effective participation of the user in the search of shared goals and objectives, aiming social insertion and citizenry reappropriation. It also seeks to understand the user’s responsibility degree for his or her own treatment, evaluating users and CAPS-ad professionals’ objectives and motivations. Divergences were found between the ones set by the users and the ones set by the professionals, revealing that there is a presence of tutelary character and little accountability for their treatment in the case of some users. A limitation was also observed in the use of the PTS instrument, with little participation of the users in its elaboration, and lacking presentation of goals and proposals for individual actions. A new PTS form has been proposed, one that encourages the user's role in the treatment and that contemplates several aspects of his or her life. In this approach, training users on the treatment premises becomes necessary, in order to promote their autonomy and effective participation in the PTS elaboration.

<p>Standardvårdplaner är vanligt förekommande inom hälso- och sjukvård och är under ständig utveckling. Standardvårdplaner är i olika grad evidensbaserade och framtagna med skiftande kvalitet. Standardvårdplaner används som ett hjälpmedel för effektivisering och kvalitetshöjning av vården för en specifik patientgrupp och är en på förhand formulerad vårdplan. Behov av ytterligare forskning efterfrågas om standardvårdplaner faktiskt minskar mängden dubbeldokumentation, leder till ökad tidsvinst och ökad vårdkvalitet. Syftet med föreliggande litteraturstudie var att göra en beskrivning av de effekter som användande av standardvårdplaner leder till. I litteraturstudien bearbetades 10 vetenskapliga artiklar som grund för resultatredovisningen. Resultatet visar att standardvårdplaner kan höja vårdkvaliteten, minska mängden dubbeldokumentation och leda till att tid frigörs till patientnära arbete. Det finns emellertid studier som visar på det motsatta. Standardvårdplanen kan ses som ett verktyg som underlättar en jämlik, högkvalitativ vård till alla patienter oavsett vem som vårdar. Utveckling av standardvårdplaner i vården bör ske på ett strukturerat och vetenskapligt sätt och tid till detta bör prioriteras. Litteraturstudien redovisar motstridiga resultat vilket indikerar behovet av fortsatt forskning av vilka effekter standardvårdplaner har för vården, både sett ur patientperspektiv, personalperspektiv samt ur ett organisatoriskt perspektiv.</p> / <p>Standardized care plans are commonly used in health care and are under constant development. Standardized care plans are to varying degrees evidence-based and designed with varying quality. Standardized care plans are used as a tool for improving the quality of care and are seen as a pre-formulated treatment plan. Research is needed into whether standardized care plans reduce the amount of redundant documentation, save time and increase quality of care. The aim of this literature study was to describe the situation regarding effects of using standardized care plans. In this study 10 scientific articles were analyzed. Results show that standardized care plans can improve quality of care, reduce redundant documentation and decrease time spent on documentation. However, there are studies that demonstrate the opposite.<strong> </strong>Standardized care plans can be seen as a tool for providing high-quality basic care for all patients. Scientific evidence should be used for development of standardized care plans and therefore priority should be given to making resources for this work available. There is a need for further research to validate the effects of standardized care plans as the results from this literature study are ambiguous. It would also be interesting to compare the views from patients, staff and management on the effects of using standardized care plans.</p>